Healing Touch in Patient Care, Essay Example

Abstract

As an alternative, energy-based therapy, the central thesis of Healing Touch is that healing is not only physiological, but also a process that takes place on the plane of universal life-energies. This perspective is nothing new: though Healing Touch was created in 1989, it is rooted in ancient Eastern philosophies, whence it derives the concept of a universal life-energy, called qi in Chinese or prana, “vital force”, in Sanskrit. The practice itself consists of the adoption of a meditative and intentional state of awareness by the practitioner, who then draws on the universal life-energies to help their patient achieve a better flow of energy. Far from mere mysticism, Healing Touch is an approach that is garnering increasing validation from science, with the discovery that all living things emit electromagnetic frequencies, and healers emit frequencies identical to the resonant frequencies of the Earth itself (Johnston, 2009, p. 19).

A number of studies vindicate the application of Healing Touch. The therapy has been linked to marked improvements in the condition of patients, from the reduction of stress, depression and anxiety to better management of pain. Healing Touch helps patients to feel more relaxed, sleep better, and generally have a better outlook on life. Healing Touch has helped coronary artery bypass patients to recover from surgery more quickly, and has reduced stress and improved wellbeing for acute lymphocytic leukemia patients. It has also helped patients with chronic pain to experience greater relief. In one particularly stunning study, Healing Touch was even linked to improved growth of cultured cells. Moreover, Healing Touch has been very popular with the patients that it has helped, with many desiring more sessions. Although further research is needed to better understand Healing Touch from the perspective of science, its essential vision has been vindicated: a vision of healing that is holistic and ecumenical, grounded in ancient wisdom, compassionate awareness, and a deep connection with the biofield energies that pervade all living things.

Healing Touch is an alternative, energy-based therapy which offers exciting new prospects for nurses in their clinical practice. The literature provides support for the theoretical perspective underlying Healing Touch, which draws upon the concepts of using energy fields, chakras, and an expanded awareness to promote health and well-being. Indeed, Healing Touch has much to offer the nursing profession: it is a holistic, compassionate therapeutic approach, one which has been linked to the alleviation of chronic pain, depression, fatigue, the reduction of stress, and attendant positive effects for patient health and peace of mind. Healing Touch offers an alternative course of treatment that enables patients to expand their own awareness and improve their quality of life, even as it ameliorates their pains and worries. As nurses seek to implement their mission in society, to alleviate pains and promote health and well-being, an increasing number are finding that Healing Touch offers a new way to achieve desired treatment outcomes.

Healing Touch is an energy-based alternative therapy, one that is grounded in the conception that our connection with universal energies is seminal to health and well-being (Johnston, 2009, p. 19). The program itself was created in 1989, by a registered nurse, and it has since gained certification through the AHNA (p. 10). Johnston (2009) explained the theoretical underpinnings of Healing Touch, proffering an etiology of health and disease that is correlated with the individual’s attunement to the resonances of ‘universal energies’: the central thesis of Healing Touch is that “our physiology is subordinate to our energetic nature” (pp. 19-20). Whilst this conception may appear to be nothing more than metaphysical speculation, Johnston explained that in fact, it is grounded in science: “Although most people emit a variable electromagnetic frequency from their hands, scientists have shown that healers emit a steady frequency that is identical to the Earth’s resonant frequency” (p. 19).

Not surprisingly, Healing Touch draws upon venerable healing philosophies of the East: the life-force which is integral to Healing Touch might be described as qi or prana, and Healing Touch also borrows the concept of chakras, vortexes of energy that are believed to serve as the body’s own energy-processing centers (Johnston, 2009, p. 20). In fact, the methodology of Healing Touch is designed to channel energy through the chakras, ensuring that they are open and able to accommodate the flow of energy (p. 20). A crucial point here is that the chakras are linked to various organs and their corresponding functions: in essence, they serve as the conduits of the body’s own energy-based circulatory system (pp. 20-21). Again, science provides some empirical support for these ideas, with new technologies revealing that “we all glow with visible-spectrum light; it’s just too dim for most of us to observe” (p. 21).

But there is another aspect of Healing Touch that is absolutely crucial for practice: a transcendental consciousness informed by compassion and genuine care for the well-being of others (Johnston, 2009, p. 19). Healing Touch is not simply the manipulation of life-energies through chakras: it is practiced with the adoption of a higher kind of consciousness, one that allows practitioner and client to connect not only with each other, but also with the universal life-energies (p. 19). The methodology starts with the healer finding their own internal center, their “greater intuitive self”: accessing this self allows the healer to become more attuned to the patient (p. 21). This in turn facilitates the healer’s efforts to harmonize the patient with the “universal healing resonance” (p. 21).

Although the therapy is called Healing Touch, in actuality no physical contact is needed: the healer can use their hands or an implement such as a divining rod to ‘scan’ for energy imbalances (Johnston, 2009, pp. 21-22). Healing Touch practitioners may experience energies as “hot, cold, tingling, congested,” and other sensations (p. 22). In fact, as MacIntyre et al. (2008) explained, Healing Touch promotes relaxation and bodily healing, and it does so by means of “intention (such as the practitioner centering with the deep, gentle, conscious breath)”, and (2) “placement of hands in specific patterns or sequences either on the body or above it” (p. 24). The basic idea is that the body is a kind of ‘energy system’ consisting of multiple dimensions, which can be positively affected by the practitioner (p. 24). Again, there is scientific support for this: MacIntyre et al. explained that Princeton University’s Engineering Anomalies Research Program is researching info-energetic connections of this type (p. 25).

As Stearn (2012) explained, so-called ‘energetic medicine’ is believed to be efficacious for promoting a balance between the mind, the body, and the spirit (p. 10). This balance is seminal to an understanding of Healing Touch: when the mind is quieted, then the body can be rejuvenated the more profoundly (p. 10). By working with the energies, Johnston (2009) explained, Healing Touch practitioners can affect a number of beneficial treatment incomes, including: accelerated healing from surgery and wounds; a reduction of “pain from many causes”; a decrease of dementia-related behaviors; behavioral improvement in cases of Alzheimer’s; an amelioration of depression, and a reduction of stress for clients such as “recovering alcoholics, abused women, children with disabilities, neonates, students,” and others (p. 22). Healing Touch also appears to ease the suffering of hospice patients, and reduces “depression, anxiety, anger, and fatigue levels associated with cancer radiation” (p. 22).

In light of the evidence presented above, Healing Touch and a related technique, Therapeutic Touch, are a good investment for advanced practice nurses (Vickers, 2008, p. 46). This is the more evident in light of the fact that mental disorders accrued costs of $47.5 billion in 2002, up from $36.2 billion in 1997, and both Healing Touch and Therapeutic Touch are very cost-effective (p. 46). Vickers (2008) reviewed three studies that assessed the efficacy of Therapeutic Touch or Healing Touch, and found significant support for these techniques (pp. 47-48). In particular, the therapies were linked to reductions of anxiety and other psychological symptoms, particularly depression, increased relaxation, and lowered blood pressure (pp. 47-48). However, Vickers added some essential precautions: whenever possible, practitioners should consult with the psychiatrist or other specialist working with the patient; failing that, the practitioner should familiarize themselves with the particulars of their client’s disorders (p. 49). Vickers also advised advanced practice nurses to “provide direct and detailed information regarding what is going to occur” ahead of time, whenever they work with psychiatric patients; this is particularly imperative with clients who are afflicted with hallucinations (p. 49).

A key question, of course, is how to account for the effects of Healing Touch and Therapeutic Touch. According to Vickers (2008), the Science of Unitary Human Beings (SUHB) developed by Martha Rogers, and the Human Energy Model developed by Susan Leddy provide the theoretical background (p. 46). The SUHB model, in particular, consists of four interlinked concepts which are quite congruent with both Healing Touch and Therapeutic Touch: “patterns, pandimensionality, energy fields, and open systems” (p. 49). Both Healing Touch and Therapeutic Touch can be used to establish beneficial, healthy energy patterns in the human body, particularly by alleviating the effects of changes in the interactions between two patterns (p. 49). Pandimensionality is a holistic perspective, concerned with the idea that “’…human beings are more than and different from the sum of their parts’” (Rogers, 1970, qtd. in Vickers, 2008, p. 49). Energy fields are, in the SUHB model, the “fundamental unit of the human being”: constantly changing, their fluctuations can sometimes disrupt the function of the whole (p. 50). Accordingly, both Healing Touch and Therapeutic Touch are useful for their ability to restructure and rebalance energy fields (p. 50). A key structural reason for the imbalances in energy fields is the fact that the human body is an open system: in other words, the imbalances in the energy fields often result from changes caused by interactions with the outside environment (p. 50). Again, both Healing Touch and Therapeutic Touch offer the means of restoring the patient to balance, both internally and externally (p. 50).

Similarly, Leddy’s Human Energy Model (HEM) offers a theoretical perspective that is fully compatible with, and supportive of, both Healing Touch and Therapeutic Touch (Vickers, 2008, p. 50). The three main concepts associated with the HEM model are: “healthiness, participation, and energetic patterning” (p. 50). Energetic patterning, in particular, offers a compelling theory of healing fully consonant with Healing Touch and Therapeutic Touch, one that “’proposes that healing nursing interventions facilitate field energy movement and resonant pattern manifestations of both the client and the nurse healer’” (Leddy, 2004, qtd. in Vickers, 2008, p. 50). The congruence between both the HEM and the SUHB on the one hand, and the core concepts of Healing Touch on the other, gives attestation of the theoretical support for Healing Touch. How, then, does the therapy stand up in practice?

Stress is a significant concern in the nursing field: as Tang, Tegeler, Larrimore, Cowgill, and Kemper (2010) explained, chronic levels of stress are all too common in the field, and this phenomenon of chronic nursing stress is a significant occupational hazard (p. 837). If Healing Touch could be shown to be effective in alleviating chronic nursing stress, this would have significant ramifications for nursing practice: the therapy could be used to improve nurses’ performance (p. 837). Accordingly, Tang et al. conducted a quasiexperimental study of the stress-alleviating effects of Healing Touch in a group of nursing leaders (p. 837). Heart rate variability (HRV) was the metric used to assess levels of stress: as the authors explained, HRV is useful for measuring “autonomic balance and coherence, which might be considered aspects of well-being” (p. 837). The intervention itself consisted of a Healing Touch instruction course, taught by a registered nurse with certification as a Healing Touch Instructor (p. 838). At baseline, the twenty nurses who completed the program and the six who did not evinced many similarities in measurements of stress and well-being; however, non-completers evinced lower levels of relaxation “(VAS score 3.4 versus 4.7, p=0.07),” poorer sleep “(VAS score 3.6 versus 5.1, p=0.03)”, and generally experienced greater sensations of feeling rushed for time “(VAS score 8.4 versus 6.2, p=0.03)” (p. 838).

The results of the intervention were quite encouraging: firstly, the participants evinced high rates of Healing Touch adoption, both for their own care and for that of their patients (Tang et al., 2010, p. 839). Participants reported making use of Healing Touch therapy for personal use about 2-4 times per week, and for the care of their patients, once a week (p. 839). Participants also reported improvements due to Healing Touch in their levels of “stress, depression, anxiety, relaxation, well-being, and sleep” (p. 839). Tang et al. also noted a very interesting result regarding participants’ feelings of being rushed, experiences of pain, and levels of job satisfaction: the results did not indicate a statistically significant change, due to the ‘ceiling effect’ caused by participants with a high level of job satisfaction before the intervention (p. 839). Once these participants were removed from the consideration of the data, there was a statistically significant improvement in job satisfaction (p. 839).

Other results were very significant as well: two of the participants had had to deal with very negative experiences in the course of the follow-up period, “1 death in the family; 1 hospitalized child”, but both of these participants found Healing Touch to be efficacious in the process of coping with these events (Tang et al., 2010, p. 839). Blood pressure did not improve, but at baseline the average was “113 ± 9.7 mm Hg/71 ± 6.8 mm Hg, with a range of 96-142/64-82” (p. 839). However, a number of HRV metrics did evince improvement: “total power (TP), low frequency (LF), high frequency (HF), and coherence” (pp. 837, 839). These are all important indicators that Healing Touch is an efficacious therapy for increasing well-being. In particular, it is noteworthy that the participants evinced improvements in a number of different dimensions of health and well-being, ranging from better coping skills when dealing with negative life events, to reduced stress, depression, and anxiety and better sleep patterns more generally, to improved HRV measures. This suggests that Healing Touch has positive and beneficial effects on a deep psychological level, and can affect very substantial improvements in the well-being and state of mind of an individual.

Tang et al. (2010) effectively vindicated the use of Healing Touch to alleviate chronic nursing stress and improve nurses’ performance. It is especially notable that their results found improvements both in participants’ self-reported well-being, and in participants’ “autonomic nervous system function as reflected in HRV” (p. 839). The study sample was small: the authors reported that “24/26 enrollees completed the training and 20/24 completed the outcome assessment” afterwards (p. 839). And a key limitation of the study is the question of whether or not a different type of therapy could have achieved similar results: after all, there are many other kinds of stress management training, and the study did not compare Healing Touch with such therapies as “mindfulness-based stress reduction” (p. 839). Still, the findings are very intriguing, and they suggest that Healing Touch could be used efficaciously to improve the wellbeing of nurses as well as of patients (p. 839).

Inasmuch as a comparison between Healing Touch and another stress management therapy would be salient, the findings of MacIntyre et al. (2008) are particularly of interest. MacIntyre et al. (2008) investigated the effects of Healing Touch on patients who had undergone elective coronary artery bypass (CAB) surgery (pp. 24, 26). The group consisted of 237 patients in all, subdivided randomly into three groups: the full intervention group, who received Healing Touch therapy; a second group that received a kind of ‘partial intervention’ with visitors, but not Healing Touch, and a control group (p. 26). The importance of this is not difficult to see: after all, if the only groups consisted of a full intervention group receiving Healing Touch and a control group receiving no additional treatment, this would raise the possibility of questions as to whether the treatment itself was efficacious, or if the members of the intervention group were simply displaying a placebo effect. The Healing Touch interventions were 20-60 minute sessions, except for a longer session of 60-90 minutes on the day of surgery (p. 26). The visitor group, on the other hand, received visits from a retired registered nurse, which again lasted for 20 to 60 minutes, except for a longer visit on the day of surgery, lasting 60 to 90 minutes (p. 26).

The study itself evaluated 6 outcome measures: “postoperative length of stay, incidence of postoperative atrial fibrillation, use of anti-emetic medication, amount of narcotic pain medication, functional status, and anxiety” (MacIntyre et al., 2008, p. 26). The State Trait Anxiety Inventory (STAI) was used to measure anxiety: this metric consists of 40 items, which evaluate “temporary and dispositional anxiety in adults” (p. 26). The Health Status Questionnaire, which consist of 12 items, was used to measure general health (pp. 26-27). The only statistically significant difference between the three groups at baseline was preoperative anxiety scores: “HT=41, visitor= 41, and control=45, P=.04” (p. 27). And the results were significant, starting with the mean length of stay: for the Healing Touch group, mean length of stay was 6.9 days “95% CI=6.1, 7.7”, compared with 7.7 days for the visitor group “95% CI-6.7, 8.7”, and 7.2 days for the control group “95% CI=6.4, 8.1” (p. 27). The comparison between the Healing Touch group and the control group is well worth reiterating and emphasizing: patients in the former group had a “120% greater chance of having a length of stay ? 6 days” (p. 27).

Other measures were also very significant, such as anxiety scores: according to MacIntyre et al. (2008) the Healing Touch group evinced the largest drop in anxiety scores, 6.3, “(95% CI=2.0, 10.6)”, compared with 5.8 for the visitor group, “95% CI=0.9, 10.8”, and 1.8 for the control group, “95% CI=2.0, 6.2” (p. 29). This is indeed a remarkable contrast, and it lends further support to the efficacy of Healing Touch in clinical practice. However, the remaining outcome variables did not evince statistically significant differences (p. 29). As the authors explained, many questions remain unanswered: it is still not understood by what mechanism Healing Touch therapy operates; thus, they explain, it is not entirely clear how the therapy achieved these results in this study (p. 30). Of course, theoretical models such as the SUHB have been proposed, but again, there are still many questions to be answered.

The findings of MacIntyre et al. (2008) are of interest for more than one reason. Firstly, these authors compared Healing Touch with another kind of therapy: the partial intervention (p. 26). This is an important control for the placebo effect, and it is the first key reason that this study is of interest. After all, if the partial intervention and full intervention groups showed no statistically significant differences, then it could reasonably be concluded that the presence of visitors is sufficient to reduce anxiety scores and in-patient hospital stays.

Again, though, the crucial point is that this is not what MacIntyre et al. (2008) found: the fact that the patients who received the full Healing Touch intervention evinced significantly shorter hospital stays than the partial intervention group, as well as the fact that both groups did considerably better than the control group, demonstrates that although receiving visitors is beneficial, Healing Touch is even more so. The therapy does indeed exert significant effects on patient well-being. The anxiety scores provide still more attestation of the same, and they constitute the second key reason that this study is of interest: while it is not surprising that the partial intervention group outperformed the control group, the fact that the Healing Touch patients outperformed the partial intervention group is very much of interest, and highly significant. Indeed, MacIntyre et al. (2008) reported that after their session, the Healing Touch patients told their Healing Touch practitioner that they had been quite unaware of their stress prior to the session (p. 30).

If Healing Touch can help coronary artery bypass patients, then it only stands to reason that it should be assessed in the field of oncology as well: after all, if it has promise for one group of patients who have undergone a medically serious procedure, why not another? Kemper, Fletcher, Hamilton, and McLean (2009) assessed the clinical impact of Healing Touch therapy in pediatric oncology patients. The participants were aged approximated nine years (mean), and most of them had been diagnosed with “acute lymphocytic leukemia,” for which they were in treatment, in the consolidation phase (p. 14). In this consolidation phase of treatment, the participants had received the medication doxorubicin, which, as Kemper et al. explained, is “a potentially cardiotoxic medication” (p. 14). The intervention itself consisted of two 40-minute monitoring sessions, delivered in the course of routine clinic visits (p. 13). The second visit included 20 minutes of Healing Touch therapy (p. 13).

Heart rate variability (HRV) was used as the metric to assess well-being, with the parameters of the “standard deviation of the interbeat interval (SDNN), total power (TP), very low frequency (VLF), low frequency (LF), and high frequency (HF)” (Kemper et al., 2009, pp. 12-13). High frequency oscillations range from 0.15-0.4 Hertz, while low frequency oscillations range from 0.04-0.15 Hertz, and very low frequency (VLF) oscillations range from 0.0033-0.04 Hertz (p. 13). Heart rate variability was measured by means of the MiniMitter 2000 monitoring unit, a device that consists of “two electrocardiograph electrodes placed on the anterior chest wall and attached to a transmitter unit… belted around the participant’s chest” (p. 13). Heart rate variability is favored as a metric because it is noninvasive, yet sensitive: it measures variability in the cardiac interbeat interval (IBI) (p. 12). A key point here is that low frequency indicates a reduction in sympathetic activity, indicating less stress: thus, LF scores are positively correlated with stress levels (p. 13). A state that is especially of interest with regard to heart rate variability is coherence: coherence is defined in terms of a peak in low frequency in light of the total power spectral analysis (p. 13). This is a physiological state that is believed to be optimal, and “associated with a sense of well-being” (p. 13). Thus, higher coherence scores represent higher well-being (p. 13).

However, the window of time and the activities the patient engages in both affect the interpretation of heart rate variability scores: as Kemper et al. (2009) explained, over a period of 24 hours, lower total power scores are seen as deleterious signs (p. 13). Within a 24-hour period, encompassing many activities, lower total power scores indicate that the patient’s health is poorer, and their prognosis is the worse (p. 13). By contrast, when an individual engages in meditation or experiences restful sleep, they should be expected to exhibit both lower total power and lower low frequency scores, and in this context such a decrease is a good sign: it indicates a reduction in sympathetic activity associated with the meditative or restful state (p. 13). This accords well with the central thesis of healing touch: that healing is not only physiological, but also involves universal life-energies. Meditation can allow the practitioner to access these healing life-energies, bringing the body back into balance.

Kemper et al. (2009) had to manage the data in order to exclude artifacts caused by motion: motion, of course, affects heart rate variability in ways that have the potential to be a confounding variable when attempting to measure the effects of treatment (p. 14). Accordingly, the authors isolated the middle 15 minutes of the sessions (p. 14). They also had to filter the data in order to exclude outlying measures of the interbeat interval: all outliers “outside a range of half to twice the mean IBI for that individual” were excluded accordingly (p. 14). If over 20% of IBI scores were outliers of such a magnitude, then that session was eliminated from the analyses (p. 14).

The visual analogue scale (VAS) scores started out relatively positive at baseline, for both visits: 5.7 to 6.9 for the positive scores, a range considered ‘generally positive’, and 1.0 to 4.4 for the negative scores, a range considered ‘not very distressed’ (Kemper et al., 2009, p. 14). Of these, Healing Touch generally had a salutary effect on the already-high positive VAS scores when compared to the rest sessions alone, but the difference was not of statistical significance (p. 14). However, the metric for stress evinced some improvement due to Healing Touch: it declined from 4.4 to 1.7, p=.03 (p. 14). There was also improvement in the overall negative VAS score, from 3.1 to 1.7 for Healing Touch versus 2.1 to 2.0 for rest, p=.03 (p. 14). And from the perspective championed by the Healing Touch approach, this is scarcely surprising: by rectifying energy imbalances in order to improve the flow of energy, a more healthful state will result.

As for the HRV data, artifacts caused by movement were the most common problem with the data (Kemper et al., 2009, p. 14). The TP metric evinced improvement, dropping in Healing Touch visits as compared with rest visits; the LF power scores were also lower, but the difference was not statistically significant (pp. 14-15). Nonetheless, the authors noted that even these results are significant, inasmuch as they demonstrate a reduction of stress levels and patterns of sympathetic activation (p. 15). Indeed, this is a well-attested pattern with biofield therapies, a pattern that confirms that these therapies have the effect of alleviating stress levels in patients (p. 15).

However, the authors argued that it was surprising to find “any statistically significant differences with HT versus rest treatments”, in light of the small sample size utilized and the fact that the patients were doing relatively well, on balance, at baseline (Kemper et al., 2009, p. 15). Moreover, the authors noted that the study had a number of important limitations, besides the small sample size: the study did not evaluate the clinical efficacy of treatment plans tailored to individual patients; multiple treatments; treatments taking place over a longer period, or combination treatments, utilizing Healing Touch with other therapeutic techniques (p. 15). Greater individualization and treatment plans taking place over a more protracted period of time may well be expected to yield greater and more significant results, in terms of patient well-being and health (p. 16).

Overall, the management of leukemia is a field which is of great interest for Healing Touch. After all, acute leukemia patients experience a very great deal of stress in the course of the diagnostic and treatment processes: they are typically hospitalized for a period of 4 to 6 weeks, at the least (Danhauer, Tooze, Holder, Miller, & Jesse, 2008, p. 89). Their quality of life (QOL) tends to be very poor indeed: such feelings as “shock, fear, anxiety, uncertainty, and helplessness” are all quite commonly reported (p. 89). Danhauer et al. sought to ascertain whether Healing Touch could improve quality of life (QOL) measures for acute leukemia patients, such as reducing stress, fear, anxiety, etc. (p. 89). The study itself consisted of a cross-sectional patient survey, accompanied by a prospective cohort trial (p. 91). In the cross-sectional survey, participants were asked about any previous uses of complementary and alternative (CAM) therapies, as well as any knowledge they might have of Healing Touch therapy (p. 91). The twelve patients in the prospective cohort was asked to complete self-report questionnaires, and to rate their levels of “fatigue, nausea, pain, and overall distress” (p. 91).

The intervention itself consisted of 30-minute sessions of Healing Touch, with a total of nine sessions in all (Danhauer et al., 2008, p. 91). The Healing Touch technique used was quite standardized, and involved two steps: firstly, the practitioner used their own mental attunement to set an intention “for the patient’s highest good”, and secondly, the practitioner then engaged in the characteristic hand positions of Healing Touch, which were again standardized (p. 92). As for the results, the quantitative measures of symptom frequency and severity, sleep, and psychological distress evinced no change from baseline to the follow-up session 5 weeks later (p. 94). However, this was not the whole of the story: patients did improve with regard to fatigue, “-1.8 on a 0 to 10 scale, p<.01” and nausea “-0.5 on a 0 to 10 scale, p<.01” (p. 94).

The qualitative results, in fact, were far more encouraging than the quantitative measures (Danhauer et al., 2008, p. 94). The participants themselves reported great enthusiasm for the intervention: a full 91% stated that they liked it “very much”, and all stated that the Healing Touch sessions were either “’quite a bit’ or ‘very much’ helpful” (p. 94). The commonest response to the therapy was that Healing Touch was relaxing and very calming (p. 94). This response was followed by others: in decreasing order, participants said that Healing Touch afforded them less pain, and less nausea (p. 95). Clearly, the therapy had very real physical benefits, and the feedback from the participants evinced a real desire for more of it (p. 95). This is good evidence that Healing Touch can indeed have positive benefits for the kind of patients who need it the most: patients who are experiencing high levels of distress (p. 95).

A key limitation of this study was the small sample size, as well as the lack of a control group (Danhauer et al., 2008, p. 95). A larger sample size would provide a much better and far more robust analysis of the benefits of Healing Touch (p. 95). A control group would also be very beneficial, in order to ascertain precisely what phenomena and changes were affected by means of the Healing Touch therapy (p. 95). In the words of Danhauer et al.: “Without a control group, it is not possible to know which changes might have occurred without the HT intervention” (p. 95). And, as previously commented upon, a key consideration when interpreting studies such as this is the question of whether or not a different therapy might have achieved many of the same results, or even all of them (p. 96).

All of the aforementioned notwithstanding, this study still offers some highly significant findings. Firstly, it attests to the fact that Healing Touch can be quite standardized, in terms of methodology: not only the hand motions, but the intentions and mindfulness of the therapist. This is a very important point for testing Healing Touch and measuring its actual effects. What this demonstrates is that the mental state of the practitioner exerts a significant influence on the outcome of the therapy, an influence that can positively improve the well-being of the patients. Further research is certainly needed to ascertain whether such quantitative measures could be improved, perhaps with more refined intentions and mindfulness on the part of the therapist. This is in and of itself a significant finding: the quantitative measures evinced no change from baseline, but the qualitative measures did. This suggests that metrics are very important, as are methodologies: if the effects of Healing Touch are to be properly ascertained, then both quantitative and qualitative measures must be taken into account in the methodology and the analysis.

The participants’ enthusiasm for the treatment is easily the most vindicating finding of all for the benefits of Healing Touch therapy. Indeed, Danhauer et al. (2008) noted that participants’ chief complaint was that the sessions were not long enough (p. 95). Moreover, most of the patients involved in the study stated their intentions to pursue continued use of Healing Touch therapy afterwards (p. 95). The quiet and relaxation that Healing Touch offers patients appears to be a very great boon indeed, and this too should be taken into account for future studies, as well as for the implementation of the therapy (p. 96).

Another study on cancer patients, conducted by Aghabati, Mohammadi, and Esmaiel (2008), is highly significant for its comparison of two therapies. These authors evaluated the effects of Therapeutic Touch on alleviating the pain and fatigue experienced by cancer patients in the course of chemotherapy treatments (p. 375). Pain management and fatigue are both major concerns for cancer patients: Aghabati et al. explained that “cancer pain is managed poorly in 80% of the patients with cancer”, and fatigue constitutes “the most frequently reported symptom of cancer patients” (p. 375). As Therapeutic Touch is quite similar to Healing Touch, with its emphasis on energy fields, prana (Sanskrit for “vital force”), and the chakras or energy vortices, this study holds a great deal of promise for evaluating the efficacy of Healing Touch as well (p. 376). Both therapies share an essentially identical concept of the etiology of disease: disease is not only physical, but also the result of imbalances in energy fields (p. 376).

As stated, this study is especially invaluable because the authors made use of three groups: an experimental group which received Therapeutic Touch treatment, a placebo group treated with a ‘mimic’ treatment, and a control group (Aghabati et al., 2008, p. 376). In the experimental group, the patients received five daily sessions of Therapeutic Touch, while in the placebo group, the mimic treatment utilized the same motions as did the Therapeutic Touch treatment, but without the centering procedure (p. 377). In the experimental group, the patients received an explanation of the procedures of Therapeutic Touch prior to the intervention (p. 377). In essence, the Therapeutic Touch intervention involved “centering, assessment, TT administration… [and] reassessment of the patient’s energy field and additional treatments as needed” (p. 377, orig. emph.).

All of this is important, because it goes a very long way towards answering the question of whether or not Healing Touch and Therapeutic Touch are efficacious in and of themselves. After all, if the ‘mimic’ treatment were to prove to be as effective as either therapy, then this would suggest that the improvements are due to the placebo effect, and the patients are getting better simply because of the attention, and perhaps due to the perception of treatment as well. The key difference between Therapeutic Touch and the mimic treatment was the biofield energy principle: the Therapeutic Touch intervention utilized it, while the mimic treatment simply copied the hand motions (Aghabati et al., 2008, p. 377).

However, Aghabati et al. (2008) found that in fact, the Therapeutic Touch treatment did have a positive and significant effect on reducing the pain of the cancer patients in the control group, and the difference between the control group and the placebo group was manifest as early as the second day (p. 378). For fatigue, the experimental group who received the Therapeutic Touch treatment again did better than the placebo and control groups: from the first day on they experienced reduced fatigue compared with the control group, and from the second day on they experienced reduced fatigue compared with the placebo group (pp. 378-379). This is indeed compelling evidence that Therapeutic Touch and Healing Touch really do work, and that all components of the therapies are necessary: it is not enough to simply use the gestures, the practitioner must also practice attunement of consciousness with the energies needed to work the therapy efficaciously.

The findings of Aghabati et al. (2008) are very much of interest for evaluating the efficacy of Healing Touch. As seen, the mimic treatment was somewhat productive, but the results that it yielded were not as great as those of Therapeutic Touch. Since Therapeutic Touch and Healing Touch draw upon the same essential concepts and theoretical predilections, these results are applicable to considerations of Healing Touch as well as considerations of Therapeutic Touch. And the fact that the results were so promising gives a firm indication that Therapeutic Touch and Healing Touch can reduce fatigue and pain in cancer patients, alleviating these deleterious aspects of their condition. These are clearly very promising therapies from a nursing perspective.

Another Therapeutic Touch study took the central ideas of both Therapeutic Touch and Healing Touch to their logical conclusion: if these therapies affect bodies, why not cells? In this fascinating study, Gronowicz, Jhaveri, Clarke, Aronow, and Smith (2008) studied the effects—or lack thereof—of Therapeutic Touch, a sham treatment, and no treatment at all on cultured samples of “fibroblasts, tendon cells (tenocytes), and bone cells (osteoblasts)” (p. 233). The cells were all obtained from discarded samples: the osteoblasts from bone fragments produced as medical waste in orthopedic foot surgery, the fibroblasts from “neonatal foreskin derived during routine circumcisions”, and the tenocytes from hamstring tendons that were, as with the bone fragments, discarded as medical wastes in the course of orthopedic procedures (p. 234). As with the study described above, by Aghabati et al., the sham treatment consisted of similar hand motions, while the Therapeutic Touch therapy was conducted by trained practitioners in the discipline (p. 234).

And the results were nothing short of astounding: as Gronowicz et al. (2008) explained, the Therapeutic Touch treatment produced “a significant difference in cell proliferation compared to control (p = 0.04) and sham treatment (p = 0.04)” for the fibroblasts (p. 236). The osteoblasts treated with Therapeutic Touch outperformed the control group (p = 0.01) in terms of cell proliferation, though not the sham treatment (p = 0.2) group (p. 236). Finally, for the tenocytes, cells treated with Therapeutic Touch outperformed both the control (p = 0.01) and the sham treatment (p = 0.05) groups (p. 236).

This research casts a great deal of light on the potential of Therapeutic Touch and Healing Touch to promote health and well-being in the human body, even at the cellular level. The very idea seems counter-intuitive: why should a biofield therapy have any relevance to cultures of cells in a laboratory? And yet, it is the logical conclusion from the theoretical concepts and interpretations that provide the basis for both Therapeutic Touch and Healing Touch: if life itself is associated with biofield energy, then these therapies should have some relevance even to cultured cells. The fact that the authors of this study set out to test this idea is nothing short of brilliant, and inspired: it demonstrates the applicability and relevance of the biofield concept.

Another way in which this study is especially interesting concerns consciousness: the fact that the subjects of the intervention were cultured cells without a consciousness demonstrates that these biofield therapies work even when the “patient” does not possess a consciousness. The key point here is that with a patient, Therapeutic Touch and Healing Touch both focus on the patient’s consciousness as well as that of the practitioner. After all, so much of both of these therapies is concerned with helping patients to reduce stress, fatigue, worry, fear, and the like. And yet, they work on cultured cells, in the capacity of promoting growth!

It has already been remarked that Healing Touch therapy has been found to have an impact on alleviating pain. In their study, Sutherland, Ritenbaugh, Kiley, Vuckovic, and Elder (2009) investigated the use of Healing Touch as a pain management therapy (pp. 819-820). They explained that in the United States alone, over 50 million people are afflicted with chronic pain, and an estimated 40% of people afflicted with moderate to severe pain experience scant relief (p. 819). The study itself was conducted at the Kaiser Permanente Northwest (KPNW) Pain Management Clinic, with the goal being to evaluate the effectiveness of Healing Touch and whether it would be an appropriate treatment for KPNW or any other similar health maintenance organization (HMO) to endorse, and, if so, how many sessions should be implemented for a course of treatment, and what range of outcomes should be expected (p. 820).

Consisting of a single trial, the study was composed of two consecutive waves: the first wave consisted of six patients afflicted by chronic headache (Sutherland et al., 2009, p. 820). The second wave was composed of patients afflicted with temporomandibular joint disorder (p. 820). In the course of the first wave of treatments, six treatment sessions were offered; however, of these, some three participants elected to terminate the sessions after the first three, and a fourth elected to do the same owing to conflicts with their work schedule (p. 820). Accordingly, the protocol was modified for the second wave, which was informed by the first: three treatment sessions were offered to the participants, who were given the option to proceed with an additional three treatments if, in consultation with their practitioner, they determined that it would be both desirable and efficacious for them to continue (p. 820). The net result was that some 13 participants “received at least 3 energy healing treatments,” whilst others received additional treatments (pp. 820-821).

The data collection methodology was qualitative, relying on interviews (Sutherland et al., 2009, p. 821). In the first wave, in-person interviews were conducted at baseline and after the sixth treatment, while phone-based interviews were conducted after the third treatment and in 3-month follow-ups (p. 821). With the second wave, in-person interviews were conducted at baseline and after the third treatment, and phone-based interviews were conducted at a two-month follow-up (p. 821). Most of the interviews were semistructured, utilizing open-ended questions to encourage participant feedback (p. 821). The interviewers were assiduous towards the collection of something of the patients’ own stories, concerning their experiences of the chronic pain (p. 821). The end of treatment (EOT) interviews were different, inasmuch as they made use of a specific tool, a “card sort of 37 phrases developed from validated questionnaires”; written upon each card was a short but descriptive sentence pertaining to the healing process (p. 821). The participants were asked to select the cards based upon their own visceral response to them, as opposed to their mental responses, and they were then asked to go through the cards one more time to see if they would have chosen any others (p. 821).

As Sutherland et al. (2009) explained, the results were indeed significant: there were significant improvements in the first wave of the study, at the latest by the time of the interview that occurred after the third treatment (p. 822). Whether it was a reduction in frequency, a reduction in intensity, or a reduction in duration, all participants reported some improvement (p. 822). Moreover, all participants reported other positive effects as well, pertaining to experiential effects: better awareness of self, for example (p. 822). Encouragingly, these positive improvements were noted by other people as well: participants reported that others had told them “about how ‘different,’ ‘relaxed,’ or ‘calm’ they seemed” (p. 822). Moreover, these positive outcomes persisted beyond the course of the treatment, at least for the two participants that the researchers were able to collect information from (p. 822).

The second wave of the study evinced similar improvements: as with the first wave, six participants (out of seven) experienced some amelioration in their pain no later than the interview after the third treatment (p. 822). Five out of the seven reported positive improvements in the experiential domain, similar to those from the first wave, and of these two reported that others had commented on the positive difference (p. 822). Moreover, three out of the six who reported improved outcomes by the third interview reported that they had continued at the two-month follow-up (p. 822). The results were sufficient for the authors to recommend the inclusion of the Healing Touch therapy as part of the pain management regimen (p. 825). Although it is indeed of interest that not all of the participants from the second wave experienced lasting effects of treatment, this may evince the need for more sessions in some cases, or the integration of Healing Touch with other treatment techniques.

A key problem in assessing the efficacy of biofield therapies has been the lack of robust studies (Sutherland et al., 2009, p. 825). In a critical review, Jain and Mills (2009) examined some sixty-six clinical studies on the effects and outcomes of a variety of biofield therapies, including Reiki as well as Healing Touch, Therapeutic Touch and others (p. 1). The authors noted participant information; the particulars of the intervention descriptions; methodology, wherein all studies were classed as “either between-subject or within-subject designs”; statistical methods, wherein points were awarded for “proper data analysis procedure, alpha control, and assessment/use of covariates”, and outcomes assessed, with points awarded for “multiple types of outcomes assessed… and use of reliable/valid measures” (pp. 3-4). The overall quality of each study was assessed on a total quality scale, ranging from a lowest possible score of -3 to a highest possible score of 16 (p. 4). In order to be included, studies also had to meet minimum standards for best evidence synthesis: firstly, they had to demonstrate an appropriately-conducted and sufficiently described set of data analysis procedures, and secondly, they had to “include an adequate control, comparison, or placebo control group or condition” (pp. 4, 6). They were then classed from strong evidence (level 1) to conflicting evidence (level 4) (p. 6).

The results were 52 studies utilizing “between-subjects randomized controlled trials,” and 14 studies utilizing “within-subject repeated measures” (Jain & Mills, 2009, p. 6). Studies utilizing mock or placebo-controlled treatment groups numbered 31, while the number of those using comparison groups was 11, and the number without any treatment or control groups was 32 (p. 6). The authors’ most disappointing finding here was that some 69% of the studies did not report participants’ ethnicities (p. 7).

As for quality, on the scale from -3 to 16, the study scores ranged from 1 to 12, with a mean of 6.4 and a median of 6 (Jain & Mills, 2009, p. 7). These scores are of middling quality, an unfortunate finding (p. 7). For methodology, on a scale of 0 to 8, the studies earned 1 to 6, with a mean of 2.9 and a median of 3 (p. 7). Thus, the methodologies left a great deal to be desired: in fact, only a little over half of the studies explained the procedures utilized for randomization (p. 7). Another finding was that less than a third of the studies “reported blinding of outcome assessors”, and still another was that a mere 53% reported rates of attrition (p. 7). On statistical criteria the studies performed very poorly: on a scale of -2 to 6, studies earned -2 to 5; 2.2 was the mean score and 2, the median score (p. 7). And on an outcome measure scale of 0 to 2, the studies earned 0 to 2; 1.4 was the mean score and 1.5, the median score (p. 7). Put simply, the performance of most of these studies was average, at best (p. 7). This indicates very clearly the need for better and more robust studies to assess the effects of Healing Touch.

For the best evidence syntheses, the authors divided the studies by category: thus, there were fifteen studies pertaining to pain-related disorders, and of these two were plagued with “poor statistical procedures and/or reporting” (Jain & Mills, 2009, p. 8). The remaining thirteen fared somewhat better: of these, nine were found to be high-quality studies utilizing randomized controlled trials (RCTs), while another was found to be a quasi-experimental study of high quality (p. 8). Of the remaining three, one was a quasi-experimental study of lower quality, and the remaining two were RCTs of lower quality (p. 8). Overall, the data from these aspects of the studies in question provided strong support, evidence level 1, of the beneficial effects of biofield therapies with regards to pain-related disorders (p. 9).

Next were the ten studies reporting on cancer patients: of these ten, one was problematic due to questionable statistical analysis procedures, while another “became quasi-experimental due to the healer unblinding his status and quitting the study” (Jain & Mills, 2009, p. 9). The remaining eight studies were divided equally between studies of high quality and studies of low quality (p. 9). In sum, these studies provided level 2 evidence support, which is moderate, for the beneficial effects of biofield therapies in the reduction of pain caused by cancer (pp. 9-10). However, the track record was much poorer with regard to the five studies evaluating biofield therapies’ effects on alleviating fatigue: in sum, they provided conflicting evidence, evidence level 4, for this claim made about biofield therapies (p. 10). Another area in which the cancer studies performed poorly, delivering level 4 evidence, was with the three studies that evaluated biofield therapies’ effects on cancer patients’ quality of life (p. 10). Two studies assessed physiological measures associated with relaxation: here, one study supported the position that biofield therapies (specifically Healing Touch) do improve these measures, while another study, using Reiki, did not find support for this position (p. 10). Thus, in this particular, the studies provided level 4 support (p. 10).

For hospitalized and postoperative patients, Jain and Mills (2009) found level 2 or moderate support for the position that biofield therapies have beneficial effects in alleviating anxiety (p. 11). There was also level 2 evidentiary support for reduction in pain, and level 4 support for reductions in the dosage of pain medications (p. 11). For dementia, the authors similarly found moderate, level 2 evidence supporting the position that biofield therapies can reduce behavioral symptoms; however, they also indicated that the moderate support is both promising and important (p. 11). For cardiovascular patients, the studies performed poorly: conflicting, level 4 evidence for the position that biofield therapies alleviate anxiety, and the same for the position that they “may reduce diastolic blood pressure” (p. 12). Overall, this indicates a very clear and great need for more studies of better quality: Healing Touch advocates have produced some quality work, but not enough of them have done so consistently.

Conclusion

The evidence here presented provides significant support for the beneficial effects of Healing Touch and its similar cousin, Therapeutic Touch, in clinical practice. These therapies have been linked to alleviation of pain, stress, worry, anxiety, and other symptoms of ill-health. Drawing on the wisdom of ancient Eastern philosophies, Healing Touch borrows and makes use of concepts such as qi, also called prana: the vital, universal life-force that pervades all things. Healing Touch also utilizes the concept of chakras, the energy-vortices: by entering a meditative state of compassion and awareness, the Healing Touch practitioner can rectify imbalances in the chakras, in order to improve the flow of energy.

Indeed, perhaps Healing Touch’s greatest and most seminal feature is its view of healing as being more than merely a matter of physiology. The balance between body and mind and spirit is integral to an understanding of Healing Touch and its effects: the central idea is far more than manipulating the flows of biofield energy in the patient. To explain this further, Healing Touch utilizes consciousness and awareness to help the patient’s mind to relax, in order to affect a rejuvenation of the body (Stearn, 2012, p. 10). The literature has demonstrated that this approach is indeed efficacious: patients who experience Healing Touch feel less fatigue, stress, worry, and other mental and emotional symptoms, but also have shorter hospital in-patient stays and less pain. The mind and the body are linked, and Healing Touch is built on a recognition of this essential truth.

With a view of healing that goes beyond the limitations of the biomedical model, Healing Touch advances the understanding and discourse of nursing practice. Wellness and illness are not solely the province of the body: they are also the province of the mind. Body and mind are in turn affected by the flow of biofield energy through the chakras. This is the great advancement that Healing Touch offers nursing practice: medicine that goes beyond the physical to the mental, emotional, and spiritual domains.

Grounded in a compelling theoretical perspective that proposes a view of healing that is more than physical, a view of healing that incorporates expanded consciousness and life-energies, it should come as scant surprise that Healing Touch and Therapeutic Touch offer promising prospects for new kinds of treatments which can improve patients’ health and well-being. The scientific understanding of the biofield phenomenon is still in its infancy, but the results of the studies presented in this work offer much compelling evidence that biofields are a real phenomenon, and that they do impact health and well-being. From physiological measures of health and disease, such as pain and levels of blood pressure, to mental ones like fatigue, worry, and stress, Healing Touch has demonstrated its ability to make a positive difference in patients’ condition.

The comparisons of Healing Touch and Therapeutic Touch with sham or mimic treatments provide further attestation of the actual power of these therapies. The mimic treatments analyzed in the studies here presented were “partial interventions”: they made use of the kinds of hand motions that Healing Touch and Therapeutic Touch utilize, but did not incorporate the consciousness aspects of these therapies. This is a very important point: from the perspective of Healing Touch and Therapeutic Touch, the mindfulness and intentions of the therapist are a necessary prerequisite for the therapy to be effective. The hand gestures are simply tools for directing energy flows: without the correct state of mind and awareness, they are essentially useless from the perspective of biofield therapy.

If the sham or mimic treatments worked as well as did Healing Touch and Therapeutic Touch, this would provide attestation to the real nature of the phenomenon in question: the placebo effect. Hand gestures are useless from the perspective of the biomedical model, and without the appropriate awareness and mindfulness they are useless from the biofield model of Healing Touch and Therapeutic Touch as well. However, the fact that Healing Touch and Therapeutic Touch consistently outperformed the mimic treatments demonstrates that there is something more to these therapies than a simple placebo effect: they do work, and the phenomenon of biofields that they deal with would appear to be valid.

The ailments that Healing Touch can ameliorate or alleviate, and the degree to which it can do so, are nothing short of extraordinary. Healing Touch’s efficacy with regard to reducing stress and fatigue holds a great deal of promise for nurses as well as for patients. Other improvements, such as reductions in pain, depression, and anxiety, are also remarkable. Healing Touch clearly has the ability to make marked improvements in patients’ quality of life (QOL) measures, improving well-being and relaxation. The ramifications of these findings are easy to see: the use of Healing Touch can help patients in very difficult situations to manage their condition and experience greater well-being. This indicates that Healing Touch may have a great deal of potential for helping people without critical medical conditions as well, by facilitating reductions in stress, fatigue, anxiety, and the like.

Healing Touch has helped coronary artery bypass (CAB) patients and leukemia patients to experience less anxiety and pain. It even affects the body on the level of the autonomic nervous system, with improved heart rate variability (HRV) measures. This demonstrates that Healing Touch is a very powerful therapy: far from being pseudo-science, it is a therapy that can profoundly change the way people experience their lives, and in particular, the ways in which patients manage their conditions. Healing Touch’s cousin, Therapeutic Touch, has even been found to have a pronounced impact on the growth of cultured cells, despite the fact that these lack a consciousness.

Finally, the greatest vindication of Healing Touch is its popularity with so many patients. The fact that many patients have reported that they have found the therapy beneficial and enjoyable demonstrates that for so many, Healing Touch offers improved quality of life. The enthusiasm of Healing Touch patients for the therapy is the greatest endorsement of this therapy for nursing practice. Indeed, no clearer sign could be asked for that this is an effective and desirable therapy for implementation in nursing practice: the popularity of the therapy with those who have experienced it indicates that it makes an appreciable and very real difference. The improved quality of life that Healing Touch offers is the greatest gift that any therapy can give a patient, and a ready indication that Healing Touch should be incorporated with all due alacrity into nursing practice.

References

Aghabati, N., Mohammadi, E., & Esmaiel, Z. P. (2008). The effect of Therapeutic Touch on pain and fatigue of cancer patients undergoing chemotherapy. eCAM, 7(3), pp. 375-381. DOI:10.1093/ecam/nen006

Danhauer, S. C., Tooze, J. A., Holder, P., Miller, C., & Jesse, M. (2008). Healing Touch as a supportive intervention for adult acute leukemia patients: A pilot investigation of effects on distress and symptoms. Journal of the Society for Integrative Oncology, 6(3), pp. 89-97. DOI 10.2310/7200.2008.0012

Gronowicz, G. A., Jhaveri, A., Clarke, L. W., Aronow, M. S., & Smith, T. H. (2008). Therapeutic Touch stimulates the proliferation of human cells in culture. The Journal of Alternative and Complementary Medicine, 14(3), pp. 233-239. DOI: 10.1089/acm.2007.7163

Jain, S., & Mills, P. J. (2010). Biofield therapies: Helpful or full of hype? A best evidence synthesis. International Journal of Behavioral Medicine, 17, pp. 1-16. DOI 10.1007/s12529-009-9062-4

Johnston, S. L. (2009). Healing Touch & sci. PN, 19-23.

Kemper, K. J., Fletcher, N. B., Hamilton, C. A., & McLean, T. W. (2009). Impact of Healing Touch on pediatric oncology outpatients: Pilot study. Journal of the Society for Integrative Oncology, 7(1), pp. 12-18. DOI 10.2310/7200.2009.0005

MacIntyre, B., et al. (2008). The efficacy of Healing Touch in coronary artery bypass surgery recovery: A randomized clinical trial. Alternative Therapies, 14(4), pp. 24-32.

Stearn, M. (2012). Healing Touch. Nevada RNformation, 10.

Sutherland, E. G., Ritenbaugh, C., Kiley, S. J., Vuckovic, N., & Elder, C. (2009). An HMO-based prospective pilot study of energy medicine for chronic headaches: Whole-person outcomes point to the need for new instrumentation. The Journal of Alternative and Complementary Medicine, 15(8), pp. 819-826. DOI: 10.1089=acm.2008.0592

Tang, R., Tegeler, C., Larrimore, D. Cowgill, S., & Kemper, K. J. (2010). Improving the well-being of nursing leaders through Healing Touch training. The Journal of Alternative and Complementary Medicine, 16(8), pp. 837-841. DOI: 10.1089/acm.2009.0558

Vickers, C. R. (2008). Healing Touch and Therapeutic Touch in the psychiatric setting: Implications for the Advanced Practice Nurse. Visions: The Journal of Rogerian Nursing Science, 15(1), 46-52.